Intraoperative hemorrhage in revision total hip arthroplasty: a retrospective single-center study.

PURPOSE: The amount of intraoperative hemorrhages and factors associated with hemorrhages and transfusions during revision total hip arthroplasty (reTHA) have not been identified for Japanese patients. We aimed to clarify the amount of intraoperative hemorrhages, and to elucidate the factors associated with hemorrhages and transfusions during reTHA in Japanese patients. METHODS: We retrospectively reviewed patients who underwent reTHA (n = 48) and primary total hip arthroplasty (pTHA) (n = 615) in a single hospital and extracted data regarding hemorrhage, transfusion, patient comorbidities, and surgical anesthesia. We defined massive blood loss (MBL) as a hemorrhage comprising more than half of the circulating blood volume within 3 h. The odds ratio (OR) and 95% confidence interval (CI) were estimated using a multivariate logistic regression analysis. RESULTS: There was a significant difference in hemorrhages between reTHA and pTHA patients (1790 g versus 625 g; p < 0.001). Among patients with reTHA, MBL was significantly associated with younger age (OR 0.91; 95% CI 0.84-1.00; p = 0.04) and lower body mass index (BMI) (OR 0.69; 95% CI 0.53-0.91; p = 0.01). Although not significant, the incidence of MBL tended to be higher for patients with hyperlipidemia (OR 4.88; 95% CI 0.99-24.1; p = 0.051). Furthermore, the need for allogeneic transfusion was significantly associated with the number of prepared autologous blood packs (OR 0.15; 95% CI 0.07-0.55; p = 0.002). CONCLUSION: Although this study was limited by its small population and a possibility of underestimating the hemorrhage, hemorrhages in reTHA patients was two times greater than that in pTHA patients. Younger age and lower BMI increased the risk of MBL in reTHA. Preparing autologous blood decreased the risk of intraoperative allogeneic transfusion.

[Anesthetic management of six patients with surgically repaired tetralogy of Fallot undergoing the second intra-cardiac surgery].

In Japan, more than 9,000 patients with congenital heart disease reach adulthood every year with improved medical treatment, and perioperative encounter with patients requiring the second intra-cardiac operation in adulthood is more often. Tetralogy of Fallot (TOF) is the most common form of cyanotic congenital heart disease, and long-term prognosis is good. Therefore, we have more chances to care the postoperarive adult patients with TOF. This is a retrospective study in 6 patients with TOF who underwent the second intra-cardiac operation in adulthood from 2008 to 2012. Among the six patients, six had pulmonary valve replacement; four had tricuspid valve replacements or valvuloplastys; four had ventricular septal defect closures; two had right ventricular outflow tract obstruction releases; one had aortic valve replacement; and three had cryoablations. Right ventricular end-diastolic volume was 194.1 +/- 83.5 ml x m(-2) (mean +/- SD), and right ventricular ejection fraction was 38.2 +/- 4.8%. The factors which influence the anesthetic management were as follows: right cardiac failure by abnormality of the pulmonary valve; residual disease and deuteropathy of two or more combination; the risks associated with the second open chest surgery such as long operative time and severe bleeding. Perioperative management of an adult with congenital heart disease requires full understanding of its pathophysiology such as congenital heart disease, adult-specific complications, and the second open chest surgery.

[Perioperative management of lung transplantations in patients with pulmonary arterial hypertension compared with that in patients with lymphangiomyomatosis].

BACKGROUND: The number of lung transplantation has tended to increase as a treatment for patients with pulmonary arterial hypertension (PAH) and lymphangiomyomatosis (LAM) in Japan. However, we have little evidence about the comparison of perioperative management in patients with PAH and that in patients with LAM. METHODS: In this retrospective study, ten patients with PAH and seventeen patients with LAM who underwent the lung transplantations between 2006 and 2011 were enrolled. RESULTS: PAH patients received double lung transplantation with intraoperative cardiopulmonary bypass (CPB) support. Before anesthesia induction, percutaneous cardiopulmonary support (PCPS) was begun. Most of LAM patients received single lung transplantation without using CPB support and PCPS support before anesthesia induction. But sometimes during an operation PCPS support was necessary. Postoperative PCPS support showed no significant differences between PAH and LAM. The four year survival rate was 80% (PAH) and 87.8% (LAM). Pao2/FIo2 in patients with PAH and in those with LAM, %FEV10 in those with LAM after surgery improved when compared to those before surgery. CONCLUSIONS: The large difference in perioperative management between patients with PAH and those with LAM is an important knowledge for anesthesist.

[Seventeen cases of lung transplantations for lymphangioleiomyomatosis].

BACKGROUND: The number of lung transplantation has tended to increase as a treatment for patients with pulmonary lymphangioleiomyomatosis (LAM) in Japan. However, we have little evidence about the correlation between preoperative medical parameters and intraoperative complications. METHODS: A retrospective study was performed in 17 patients with LAM undergoing the lung transplantations between 2006 and 2011. RESULTS: Major intraoperative complications were as follows: hypotension, pulmonary hypertension, hypoxemia and blood loss of more than 1,000 ml. According to the medical records, no patients was diagnosed pulmonary hypertension before surgery and no preoperative parameters predicted intraoperative pulmonary hypertension. Therefore, according to the medical records it seemed difficult to predict the risk of the intraoperative pulmonary hypertension and hypotension. Intraoperative hypoxemia and the requirements of percutaneous cardiopulmonary support (PCPS) are not associated with preoperative PaO2 and %FEV1.0. Pleurodesis and the use of PCPS were significantly correlated with an increased risk of intraoperative massive bleeding. The four year survival rate was 87.8%. %FEV1.0, PaO2/FI(O) and %DL(CO) after surgery improved when compared to those before surgery. CONCLUSIONS: Although the intraoperative complications such as hypotension, pulmonary hypertension, hypoxemia and/or massive bleeding frequently occurred in patients with LAM during the lung transplantations, it was difficult to predict them except the massive bleeding of more than 1,000 ml before surgery. However, lung transplantation is a valuable therapy for patients with end-stage LAM.

[Eighty cases of monitored anesthesia care (MAC) for inguinal hernia repairs using tumescent local anesthesia (TLA)].

BACKGROUND: This paper discusses the efficacy and difficulty of the management of monitored anesthesia care (MAC) for inguinal hernia repairs using tumescent local anesthesia(TLA). METHODS: Eighty patients were retrospectively divided into four groups (all n = 20) according to the drugs used; group P (propofol), group PF (propofol and fentanyl), group PFM (propofol, fentanyl and midazolam), group PR (propofol and remifentanyl). The four groups were analyzed in terms of the applied dose, airway use, wake-up test to determine whether hernia was repaired, postoperative pain and nausea. RESULTS: More propofol was administered in group P than in group PFM and PR. Although, airway was used for nine patients, there was no difference between the four groups. Postoperative pain and nausea also do not differ between the groups. One patient in group P showed unsuccessful repair with wake-up test. CONCLUSIONS: MAC shows a beneficial effect on inguinal hernia repairs under TLA. The rate of airway use was as high as eleven percent, and maintenance of the patients' airway requires attention. In terms of wake-up test, propofol combined with opioid administration may be more effective than propofol administration alone. There was no significant difference between the groups in pain and nausea, regardless at the use of fentanyl or remifentanil.

[Early postoperative complications in patients with Moyamoya disease--a comparison of inhaled anesthesia with total intravenous anesthesia (TIVA)].

BACKGROUND: Moyamoya disease is a rare neurovascular disorder that requires special anesthetic managements during revascularization procedures. We have investigated the incidence of early postoperative complications under inhaled anesthesia in comparison with total intravenous anesthesia (TIVA) retrospectively. METHODS: Seventy-two patients undergoing revascularization procedures were divided into two groups, one with inhaled anesthesia (n = 23) and the other with TIVA (n = 49). Surgical procedures were performed under normocapnia, proper body temperature, and all patients were prevented from anemia by homologous transfusion. To avoid the variance in anesthetic managements, 39 patients under 15 years of age were picked up and divided in the same way as above. Early postoperative complications including transient ischemic attack and cerebral infarction during the first 2 weeks after operation were investigated. RESULTS: In all patients, early postoperative complications occurred in 48% of inhaled anesthesia group and in 49% of TIVA group. In patients under 15, these complications occurred in 44% and in 57%, respectively. There was no significant difference in the incidence of complications between the two anesthetic groups. CONCLUSIONS: Several previous studies reported the excellence of TIVA for revascularization procedure on the basis of regional blood flow because inhaled anesthesia may provoke intracerebral steal in moyamoya disease. Our investigation in this study revealed that both anesthetic methods have no significant difference in postoperative complications during the first 2 weeks after operation. Thus further study should be needed to verify the safety of inhalation anesthetics in patients with moyamoya disease.

[Anesthetic management of caesarean section in a patient with asymptomatic idiopathic prolonged QT interval syndrome].

A 27-year-old patient with asymptomatic idiopathic prolonged QT interval syndrome underwent elective caesarean section. We selected combined spinal-epidural anesthesia to avoid excessive sympathetic stimulation. Bupivacaine 9 mg and lidocaine 100 mg were used for spinal anesthesia and epidural anesthesia, respectively. The anesthetic course was uneventful, and the infant showed no complication during the perioperative period. In conclusion, we consider combined spinal-epidural anesthesia as a safe anesthetic strategy for caesarean section in a patient with asymptomatic idiopathic prolonged QT interval syndrome.

[A sheared off and sequestered epidural catheter: a case report].

This is a report of a retained epidural catheter segment after placement of 20-G polyethylene catheter (Hakko Medical) through 17-G Tuohy needle and 25-G spinal needle (Top Company) for a patient receiving combined spinal-epidural anesthesia. Retained catheter fragment (approximately 10.6 cm) was removed easily with small incision under local anesthesia. Electron microscopic findings of the catheter showed that the catheter might have been traumatized by the Tuohy needle through which the catheter was placed or by the spinal needle for intrathecal anesthesia, resulting in having been sheared off.